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A charge nurse on a medical/surgical unit discovered that a patient's blood pressure had risen to 200/150. She called the doctor, who ordered 10 mg of nifedipine (Procardia, Adalat), to be given sublingually. Relaying this order to the patient's nurse, a new employee, the charge nurse emphasized that the capsule must be given sublingually for the drug to work quickly.
A few minutes later, the charge nurse checked the patient and was greeted with the question: "How is this pill supposed to dissolve under my tongue?"
The charge nurse realized immediately that the new nurse had misunderstood her directions. Apparently, the new nurse didn't know that a sublingual form of nifedipine isn't available in the United States or Canada. However, the drug may be given sublingually by perforating the capsule about 10 times with a 25-gauge needle and squeezing its contents under the patient's tongue. This form of sublingual administration, which may be used only with oral nifedipine capsules, treats severe hypertension and vasospastic angina. After discarding the first capsule, the charge nurse administered another one in the proper manner. When she checked back a short while later, the patient's blood pressure had dropped to 160/110.
This kind of medication error is easily avoided. Just make sure you review and demonstrate unusual administration routes for staff members, especially new employees. The route should also be documented in the patient's chart.